NZMJ 1462.Indd

ARTICLE

Family planning unmet need and access among iTaukei women in New Zealand and Fiji Radilaite Cammock, Peter Herbison, Sarah Lovell, Patricia Priest

ABSTRACT AIM: The aim of the study was to identify unmet need and family planning access among indigenous Fijian or iTaukei women living in New Zealand and Fiji. METHOD: A cross-sectional survey was undertaken between 2012–2013 in five major cities in New Zealand: Auckland, Hamilton, Wellington, Christchurch and Dunedin; and in three suburbs in Fiji. Women who did not want any (more) children but were not using any form of contraception were defined as having an unmet need. Access experiences involving cost and health provider interactions were assessed. RESULTS: Unmet need in New Zealand was 26% and similar to the unmet need found in Fiji (25%). Cost and concern over not being seen by a female provider were the most problematic access factors for women. CONCLUSION: There is a need for better monitoring and targeting of family planning services among minority Pacific groups, as the unmet need found in New Zealand was three times the national estimate overall and similar to the rate found in Fiji. Cost remains a problem among women trying to access family planning services. Gendered traditional roles in sexual and reproductive health maybe an area from which more understanding into cultural sensitivities and challenges may be achieved.

amily planning is considered an to be in control of when to have or limit the important tool in averting maternal number and timing of children, giving them deaths and ensuring women’s repro- the autonomy and self-preservation that is F 1 ductive needs are met. The need for family needed for the maintenance of good health. planning is supported by data which shows Given the fi nancial challenges associated that an estimated 35% of all maternal deaths with supporting a growing family, being could be avoided if unintended births were able to control family size can contribute to prevented. Specifi cally, the WHO recom- greater fi nancial stability.6,7 mends that no unmet need for family plan- Although access to family planning is ning should exist, meaning that women who considered more problematic in developing do not wish to have any (more) children are countries where resources are low, minority 2 able to access family planning methods. groups in developed countries experience Reasons for non-use of modern contracep- disproportionately lower uptake of family tive methods have been stated to be largely planning services.8,9 Among Pacifi c popu- 3,4 due to access issues. This view argues that lations in New Zealand, this is the case. if family planning methods were made more In New Zealand, high teenage pregnancy accessible then unmet need would decrease. and low use of contraception characterise Access to family planning is considered Pacifi c reproductive behaviour.10,11 Despite a human rights issue.5 Along with health these outcomes, little is known about Pacifi c and wellbeing, lack of access to family women’s family planning unmet need and planning has social and economic ramifi ca- access. High national contraceptive prev- tions. Ensuring family planning accessibility alence estimates of 72.4% do not seem to warrants individuals with the opportunity refl ect the Pacifi c experience.12 Furthermore,

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unmet need in New Zealand is reported to knowledge, attitudes and practice (KAP), be 8.8%, low in comparison to other coun- unmet need and access was carried out in tries in the developed world.12 Fiji and New Zealand to investigate iTaukei Thus, there seems to be a disconnect women’s family planning behaviour. The between the overall patterns of contra- data presented in this paper focuses on ceptive use and unmet need and the the unmet need and access data from the reported experience of Pacifi c populations KAP study. Women who identifi ed as being in New Zealand. The effects of teenage preg- iTaukei and living in the fi ve major cities nancy and lack of contraceptive use found of New Zealand—Auckland, Hamilton, among Pacifi c groups can lead to long-term Wellington, Christchurch and Dunedin, disability as a result of pregnancy and and in three suburbs in Suva—Samabula, labour, and socio-economic deprivation as Valelevu and Cunningham, were invited a result of teenage pregnancy.13,14 Therefore, to participate in the study. Only women lack of access and uptake of family planning 18 years and above were included in the not only has implications on the individual survey. If women were under the age of 18 but on future generations. or did not identify as being iTaukei, ie, they were Indian or another ethnic group, they Most studies in New Zealand of Pacifi c were not included in the survey. women’s reproductive health behaviour highlight the need for more understanding Sample into social and cultural barriers to repro- The sample size goal for the survey was ductive services, as most found cultural 200 women in each country. This number sensitivities and taboos to be barriers to was needed in order to obtain at least 163 access.15,16 Paterson’s study of a group of completed questionnaires (ie, approximately Pacifi c mothers found that due to cultural 80% response rate) in each country which taboos and sensitivities, most women who would allow the study 80% power to detect did not plan their pregnancy were not a statistically signifi cant (p<0.05) difference aware of family planning and did not like of 15% between countries in the proportion discussing the topic.17 of women who have used family planning, Given these fi ndings, little has been done if this proportion was up to 40% in Fiji and 12,18 to try to capture behaviour involved with higher in New Zealand. Multistage cluster reproductive intentions and family planning sampling carried out in Fiji was based on use. Unmet need investigations give us household income and to ensure repre- that link and quantifi es the proportion sentativeness. Given the challenges with of women whose family planning needs generating representative samples among are not being met. Furthermore, although minority groups and hard to reach groups previous studies of reproductive behaviour in New Zealand, snowball sampling tech- highlight the need for more understanding niques were employed in New Zealand to of socio-cultural factors associated with get as many women involved in the study uptake, more research is needed to identify as we could. Women in New Zealand were what these factors entail and how cultural recruited through community networks, barriers might change within the New social media and Pacifi c organisations. Zealand context. Ethics This study investigates the unmet need of Ethical approval was granted by the Fiji a group of Pacifi c women, iTaukei or indig- National Health Research Council and the enous Fijian and the main barriers to health Human Ethics Committee of the University services. The study draws on the experience of Otago. Approval for working in commu- of iTaukei women in Fiji to provide insight nities in the Suva area was also granted by into unmet need and access changes that the Ministry of iTaukei affairs. Participants might occur among iTaukei in New Zealand. were provided with information sheets prior to fi lling in surveys. Questionnaires were Methods self-administered to ensure privacy and confi dentiality. Cultural protocols and sensi- Design setting tivities were observed with data collected by Between 2012 and 2013, a cross-sec- iTaukei researchers. tional survey of women’s family planning

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Survey questionnaire Women were asked to indicate whether To identify unmet need in the samples, the the following access factors were prob- defi nition presented by Bradley et al (2012) lematic when accessing medical advice or was used to inform survey questions.19 treatment: knowing where to go, getting These included women’s family planning money to go, not having a facility nearby, use, pregnancy intentions and fecundity. having to fi nd transport, not wanting to go Demographic, sexual and reproductive alone, concern there may not be a female health surveys in the Pacifi c were also provider, talking to your husband/partner used to inform questions in the survey. To about it. Chi-square tests of statistical signif- ascertain women’s experience with access, icance were used for comparison of unmet women were asked to indicate whether they need and access factors between countries. found particular access factors, eg, cost, travel, spousal communication and health Results provider characteristics, to be problematic. Overall, 352 women fi lled in a survey The survey questionnaire was available in questionnaire. A higher response rate was both the English and Fijian languages. observed in Fiji as 212 women (out of the Analysis 220 approached) or 96% fi lled in a survey, Analysis of the survey data was carried while 140 (out of the 235 approached) or out using Stata 13 statistical software. Data 60% fi lled a questionnaire in New Zealand. from each country was analysed sepa- Overall, 249 (70%) women were either rately to identify unmet need and access married or in a relationship and eligible to and then comparatively between coun- be included in the unmet need analysis. The tries to see if there were any differences mean age of women in New Zealand was in unmet need and access patterns. The 39 while in Fiji the average age of women Bradley et al (2012) defi nition was used was 36 years. Fifty-one percent of women as a framework to analyse unmet need in in New Zealand had used a family planning each country.19 Women who were not using method at the time of the survey. In Fiji, family planning methods were classifi ed as 58% of women had used a method. Among having an unmet need for spacing if they currently married women (or women in a did not wish to have any (more) children relationship) in New Zealand, 26% had an in the next two years, while those who did unmet need for family planning. Of these, not wish to have any more children in the 25% had an unmet need for spacing while future were classifi ed as having an unmet 75% for limiting (Table 1). In Fiji, 25% of need for limiting. Unmet need was only women had an unmet need for family assessed among married women or women planning. Of these, a higher proportion had in a relationship.19 an unmet need for limiting (86%) compared with spacing (14%) (Table 1).

Table 1: Unmet need in Fiji and New Zealand among currently married women; n (%).*

Fiji NZ P value N=153 N=96 Unmet need 39 (25) 25 (26) 0.608

No unmet need 114 (75) 71 (74)

Unmet need N=37† N=24† 0.132

Unmet need for limiting 32 (86) 18 (75)

Unmet need for spacing 5 (14) 6 (25)

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator. †Missing information for limiting and spacing Fjii n=2, NZ n=1. Note: p values were calculated using the Pearson chi-squared test.

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Unmet need characteristics Main barriers to accessing family One fi fth of the currently married women planning services with a primary and/secondary qualifi - Table 3 presents the fi ndings from cation in New Zealand had an unmet need analyses involving access among women in while about a third in Fiji with a primary both countries. About half of the women in or secondary school qualifi cation had an Fiji found getting money to attend a health unmet need for family planning (Table 2). facility and concern there may not be a Conversely, a higher proportion of women female provider to be problematic. Similarly with a tertiary qualifi cation in New Zealand in New Zealand, almost half of the women had an unmet need (30%) compared with identifi ed fi nancial barriers to attending a Fiji (18%). This difference however, was health facility a problem (49%). The next not statistically signifi cant. The in-country most problematic factor appeared to be differences between primary/secondary and concern there may not be a female provider tertiary qualifi cation should be noted as (36%). The proportion of women not having well. In Fiji, more women with a primary/ a health facility nearby was signifi cantly secondary qualifi cation had an unmet need different between countries. More women for family planning (31%) compared with in Fiji (39%) had a problem with having women who had achieved a tertiary qualifi - facilities nearby compared to those in New cation (18%). In New Zealand, more women Zealand (22%) (p=0.002) (Table 3). Simi- with a tertiary qualifi cation had an unmet larly, more women in Fiji reported having need (30%) compared to those who had a problems with concerns about not having primary and/or secondary qualifi cation female providers compared with New (21%) (Table 2). Zealand (p=0.010). The number of women

Table 2: Unmet need by characteristics in Fiji and New Zealand; n (%).*

Fiji n (%) New Zealand n (%) P value Age 15–24 2 (18) 2 (50) 0.218

25–34 16 (28) 7 (27) 0.950

35–44 14 (27) 13 (34) 0.456

45–54 7 (29) 2 (13) 0.216

55+ 0 (0) 0 (0)

Education qualification Primary/secondary 25 (31) 5 (21) 0.356

Tertiary 8 (18) 15 (30) 0.165

Other 5 (31) 5 (36) 0.796

Income Below average 21 (27) 14 (26) 0.401

Above average 17 (26) 7 (25) 0.939

Employment Employed 10 (23 16 (27) 0.694

Unemployed 24 (27) 7 (33) 0.540

Other 4 (40) 1 (20) 0.439

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator in each categorical grouping. Notes: P values calculated without missing numbers; calculations were carried out using Pearson chi-squared test.

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Table 3: Factors affecting women’s access to health services.

Fiji NZ P value Knowing where to go N=169 N=123 Problem 56 (33) 28 (23) 0.053

No problem 113 (67) 95 (77)

Getting money to go N=172 N=118 Problem 87 (51) 46 (49) 0.052

No problem 85 (49) 72 (61)

Not having health facility nearby N=168 N=118 Problem 66 (39) 26 (22) 0.002

No problem 102 (61) 92 (78)

Having to find transport N=168 N=118 Problem 61 (36) 33 (28) 0.139

No problem 107 (64) 85 (72)

Not wanting to go alone N=167 N=116 Problem 61 (36) 35 (30) 0.267

No problem 106 (64) 81 (70)

Concern there may not be a female provider N=167 N=118 Problem 85 (51) 42 (36) 0.010

No problem 82 (49) 76 (64)

Talking to husband/partner about it N=168 N=118 Problem 52 (31) 19 (16) 0.004

No problem 116 (69) 99 (84)

Note: p values were calculated using a Pearson chi-squared test, n (%). reporting having problems with talking to a study investigating ethnic variations in husbands about health issues was higher sexual activity and contraceptive use from among women living in Fiji (31%) compared a national cross-sectional survey in Britain, with New Zealand (16%) (p=0.004) (Table 3). minority ethnic groups were found to have signifi cantly lower contraceptive use rates Discussion compared to Caucasian women.21 Unmet need Calculations in the current study referred to any family planning method that women The unmet need among iTaukei women in might be using, therefore unmet need calcu- New Zealand was 26%, about three times the lations accounted for traditional methods as national estimate of 8.8%.12 The difference well as modern contraceptive methods. Thus, between national fi gures and the fi gures unmet need for modern contraception may found in the current study refl ect the need be greater among this population and given for further investigation into minority the low reliability of traditional methods, Pacifi c groups in New Zealand and refl ect total unmet need may be higher as well. This similar patterns in other developed coun- is important to consider given how young tries. In the US, minority women have been the Pacifi c population is in New Zealand and found to have lower contraceptive use the high rates of teenage pregnancy.10 rates compared to the national fi gures.20 In

Comparatively unmet need among iTaukei Health service access women in New Zealand was similar to Cost and concern that there may not proportions found in Fiji. This is important be a female provider were problematic to consider in light of the different level of among most women in both countries. resources available in each country and For women in developing countries like their specifi c economic contexts. The unmet Fiji, studies show cost to be a signifi cant need in both countries was similar to those barrier.24,25 Given that over one third of found in West Africa and higher than esti- the participants in Fiji found not having 12 mates in the developing world (12.8%). transport to be a problem, having facilities Most of the unmet need found in this far away would provide further chal- study referred to limiting the number lenges for access. The longer the distance of children rather than spacing and is to the health facility, the higher the cost supported by other research which found of travel, further burdening women and women preferred to use family planning to limiting their likelihood of accessing family limit rather than for spacing.19,22 The higher planning services.26 Although transport and unmet need associated with limiting may distances were not as problematic for New be due to the age structures of the samples. Zealand participants, costs of GP visit and Studies have found that as age increases and commodities may be a burden for iTaukei women have more children, unmet need women living in New Zealand. Research for spacing decreases while unmet need for in New Zealand among Pacifi c populations limiting increases.19 In the current study, have found cost to be a signifi cant barrier given the older age structures of the sample, in accessing health services.27,28 Given the it is likely that women may have reached relative availability of resources in New their ideal family size and did not want any Zealand, questions regarding effectiveness more children. and targeting of services is warranted. The fi nding that unmet need among Accessing subsidised services, eg, family primary/secondary qualifi ed women is planning clinics, needs to be effectively higher compared with those with tertiary promoted among those who may fi nd seeing education is supported by the literature.19,23 a primary health provider, eg, general prac- Therefore, the higher unmet need found titioner, too expensive. in New Zealand among those with tertiary Concern there may not be a female education is interesting and refl ects similar provider is an important fi nding as it fi ndings to those found in the Democratic highlights sensitivities around privacy and Republic of Congo, Guinea, Mali and Niger, cultural values and belief systems. These where unmet need was found to increase concerns show that women are likely to feel with women’s education. In these coun- more comfortable having female providers tries, researchers found that women with over male providers, especially when it higher education were more likely to live comes to reproduction and sexuality. This in urban areas and were found to have fi nding reiterates the concerns highlighted similar levels of unmet need, compared by other Pacifi c research around the need with those who live in rural areas.19 It is for more understanding into the cultural likely that, in the current study, because barriers associated with accessing health women were recruited from the major services and further highlights the rele- urban cities, higher unmet need among this vance of traditional gender roles within the group maybe due to work commitments reproductive patient-provider relationship and costs associated with a higher standard in New Zealand.17,29–30 of living in urban areas. Therefore, the Perhaps ensuring that primary health extra costs of raising children and career care practitioners are trained in providing commitments may be motivators for services that are culturally sensitive and women to desire to limit having children. inclusive of the respect and sacredness that Access barriers such as cost and inconve- sexual and reproductive issues require may nience (time) may further add to unmet be needed to improve cultural awareness need among this group. and competencies in service delivery.

Jameson and colleagues (1999) found so therefore, did not account for the unmet that Pacifi c women’s barriers to cervical need among women who may be single screening included being apprehensive and sexually active. It is likely that the rate about cultural backgrounds, embarrassment of unmet need maybe an underestimation and confi dentiality. The study highlighted of the true unmet need in this population. the lack of discussion of such topics in the Furthermore, given that the sampling family and the effect that this might have strategy employed in New Zealand was a on health.15 For women to discuss family snowball sample, the fi ndings are limited to planning intentions or experiences, women older women and may not refl ect younger need to be able to feel comfortable and trust women’s unmet need. Therefore, further their health practitioner. Understanding research is needed to investigate the unmet traditional gendered roles and the effect need and access barriers among younger that this might have on women’s perception women in both countries. of male providers is important to consider In conclusion, the study shows that in among Pacifi c women and their ability New Zealand, unmet need among iTaukei to access services. Improving community Pacifi c women is more prevalent than education about the importance of such existing data show and has implications on concerns to health practitioners and the other minority Pacifi c groups. Regardless steps the health system is taking to ensure of whether women lived in Fiji or New women’s matters are respected and remain Zealand, fi nancial and cultural barriers confi dential will help improve relationships challenged women’s access to services. In and trust with health providers, leading to New Zealand, better targeting of services greater accessibility of these services among is needed to ensure that minority groups Pacifi c women. like the iTaukei benefi t from the greater The fi ndings in this study should be availability of resources. Furthermore, considered in light of its limitations. Unmet addressing the fi nancial and cultural need was measured among married women barriers may lead to greater access of or women in long-term relationships, and services and lower unmet need.

Competing interests: Dr Cammock and Dr Priest report grants from New Zealand Health Research Council during the conduct of the study. Author information: Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland; Peter Herbison, Preventive and Social Medicine, University of Otago, Dunedin; Sarah Lovell, School of Health Sciences, University of Canterbury, Christchurch; Patricia Priest, Preventive and Social Medicine, University of Otago, Dunedin. Corresponding author: Dr Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1462- 22-september-2017/7361

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